Provider Demographics
NPI:1275558652
Name:JOHNSEN, BRIANNE LYNN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:BRIANNE
Middle Name:LYNN
Last Name:JOHNSEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 FRUIT ST.
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2696
Mailing Address - Country:US
Mailing Address - Phone:617-726-7938
Mailing Address - Fax:401-854-2519
Practice Address - Street 1:55 FRUIT ST.
Practice Address - Street 2:YAWKEY 2C
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114
Practice Address - Country:US
Practice Address - Phone:617-726-7938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1215363AM0700X
MA4181363A00000X
RIPA00441363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1275558652OtherNPI
RI939025129OtherRI MEDICARE GROUP NUMBER
RI414337OtherBCBSRI
RI01/15/2008OtherNHPRI
RI979005636OtherMEDICARE
RI1275558Medicaid
RI33070-7OtherBLUECHIP
TNQ06687Medicare UPIN